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DOI:
10.4103/jehp.jehp_161_19
Department of Community
Medicine, Chettinad
Hospital and Research
Institute, Chettinad
Academy of Research and
Effect of educational intervention
on the knowledge of rabies among
medical school students of Chennai
Aravind Manoharan, Vinoth Gnana Chellaiyan, M. Madhusudan1
Abstract:
BACKGROUND: Although rabies is highly fatal, with timely and correct postexposure prophylaxis (PEP)
of animal bite victims, it could be prevented. Medical school students should be trained about the
appropriate rabies management during their formative years so that they put the right practice later
on. The study was conducted to assess the knowledge about rabies epidemiology and prophylaxis
among medical students and to find the effect of an educational intervention.
MATERIALS AND METHODS: This was a quasi‑experimental study conducted with 156 third
academic year medical school students at a tertiary care teaching hospital. The study participants
were given health education intervention. A study tool assessed the knowledge of study participants
on domains such as epidemiology of rabies, pre-exposure prophylaxis (PrEP) and PEP, and national
program guidelines of rabies prevention. The study tool was administered before and after the
intervention. The impact of educational intervention was measured with scores. Wilcoxon signed‑rank
test was applied to test the difference.
RESULTS: The overall total mean pretest total score was 14.9 (±3.7) and posttest score was
22.7 (±3.23) for a maximum score of 29. The mean pretest scores for epidemiology, PrEP and PEP
and national program components were 6.09, 7.95, and 0.85 respectively. Likewise, the mean posttest
scores were 8.09, 13.26, and 1.35 respectively. There were a statistically significant improvement
in the scores after health education intervention.
CONCLUSIONS: After educational intervention, there were statistically significant improvement in
the scores of all the three domains. PrEP and PEP and national program domain of rabies need to
be emphasized during formative years.
Keywords:
Health education, intervention, medical students, rabies
Introduction about 1.9 million disability‑adjusted life
years. [2] Rabies is transmitted to other

R
Education, Kelambakkam,
abies is 100% fatal but a animals and humans through close contact
Tamil Nadu, 1Department
vaccine‑preventable disease. It with saliva from infected animals by bites,
of Community Medicine,
DM Wayanad Institute is a neglected zoonotic disease which scratches, and licks on broken skin and
of Medical Sciences, occurs in more than 150 countries of the mucous membranes. Although a number
Wayanad, Kerala, India world.[1] According to the World Health of carnivorous animals serve as natural
Organization (WHO), the number of human reservoirs, dogs are the main source of
Address for rabies deaths globally is estimated to be 61,000 human infections and pose a potential
correspondence:
Dr. M. Madhusudan,
(95% confidence interval 37.000–86.000) per threat to billions of humans.[3] In India, an
Department of Community annum based on probability decision tree estimated 17.4 million animal bites occur
Medicine, DM Wayanad approach with 84% deaths occurring in annually which accounts for an incidence of
Institute of Medical rural areas. These estimates also project 1.7%, and an estimated 20,000 human rabies
Sciences, Naseera
Nagar, Meppadi P.O.,
death occurs per annum.[4,5]
This is an open access journal, and articles are
Wayanad ‑ 673 577, distributed under the terms of the Creative Commons
Kerala, India. Attribution‑NonCommercial‑ShareAlike 4.0 License, which How to cite this article: Manoharan A,
E‑mail: madhusudan_ allows others to remix, tweak, and build upon the work Chellaiyan VG, Madhusudan M. Effect of educational
kims12@rediffmail.com non‑commercially, as long as appropriate credit is given and intervention on the knowledge of rabies among
the new creations are licensed under the identical terms. medical school students of Chennai. J Edu Health
Received: 20‑03‑2019 Promot 2019;8:208.
Accepted: 04-08-2019 For reprints contact: reprints@medknow.com

© 2019 Journal of Education and Health Promotion | Published by Wolters Kluwer ‑ Medknow 1
 Manoharan, et al.: Educational intervention in medical students
Rabies though highly fatal is 100% preventable. With
timely and correct postexposure prophylaxis (PEP)
for these animal bite victims, rabies can be prevented.
Therefore, primary care physicians should be
aware about the appropriate PEP, which includes
proper wound washing, a full course of anti‑rabies
vaccination (ARV), and local wound infiltration of
rabies immunoglobulin (RIG) into and around the
wounds to save lives, in addition to the epidemiology
to control rabies in the community. They must also
know certain do’s and dont’s with respect to the PEP
such as no application of any irritants, no interchanging
of the route of administration and regimen of ARV,
no administering of RIG in the gluteal region, and no
suturing/bandaging the animal bite wounds before
adequate management. Hence, in this context, budding
physicians should be educated and made aware about
the appropriate rabies epidemiology and prophylaxis
during their formative years in the medical school so
that they follow correct practice later on in their life.
Only few studies have been done with assessment of
knowledge about rabies and its prophylaxis before
and after educational intervention. This educational
intervention is a unique method as it used two different
modes as detailed below. In this background, the study
was conducted to assess the knowledge about rabies
epidemiology and prophylaxis among medical students
and to find the effect of educational intervention on
their knowledge.
Materials and Methods
Study design
This was a quasi‑experimental (before and after type)
study conducted among the study population with
the assessment done before and after the educational
intervention.
Study setting
The study was conducted at a tertiary care teaching
hospital in Chennai, Tamil Nadu, India. The study
duration was from September to December 2017.
Study population
The study population constitutes third academic year
medical school students (pursuing MBBS course)
at tertiary care hospital in Chennai. Medical school
students who were more than 18 years of age and
willing to participate in the study were included in
the study.
Sample size determination and sampling
Sample size calculation for one group before and after
the study design was obtained from the formula, [6]
considering a minimal effect size (E), alpha error = 0.05,
power = 80%, and standard deviation of change in
2 Journal of Education and Health Promotion | Volume 8 | October 2019
outcome (S) (within subject correlation of outcome
(r) = 0.85), (Zα = 1.96, Zβ = 0.842, E = 0.25, S = 1.1).
N = (Zα + Zβ) 2/(E/S) 2
Substituting the values, the sample size obtained was 152.
In this study, a total of 156 medical students were
included. The students of third academic year were
arranged as per their university enrollment number, and
simple random sampling was done to enroll the medical
students in the study till the sample size was achieved.
Study tool
All the study participants were administered a pretested,
semi‑structured questionnaire. In addition to certain
baseline information, the questionnaire assesses the
knowledge about rabies such as epidemiological
aspects, mode of transmission, PrEP and PEP including
vaccines and immunoglobulins, management of animal
bite wound, vaccination regimen, WHO guidelines on
prophylaxis, and national program guidelines. The
assessment of correct response was done with scores
for every question grouped into three domains, i.e.,
epidemiology of rabies, prophylaxis, and program
guidelines with maximum scores of 10, 17, and 2,
respectively.
Intervention
Pretesting information was collected using the study
tool before educational intervention. The educational
intervention was given for the duration of 1 h. The
intervention was given in two phases: lecture with
audiovisual aid for a period of 30 min on topics covering
rabies epidemiology, clinical features, prophylaxis,
management and program guidelines, followed
by a 30 min short film with audio projected which
re‑emphasized on the same aspects. After 1‑month
period, the same study tool was administered to the
study participants to collect the posttest data.
Outcomes of the study
The impact of educational intervention (lecture and
video) was measured with scores. The difference in
scores before and after educational intervention was
measured. The study participants were included
as per the inclusion criteria. The study participants
underwent 1 h educational intervention, and the same
study participants were included in postintervention
assessment done after 1 month.
Data analysis
Data were entered into Microsoft Excel Spread Sheet and
analyzed using Statistical Package for Social Sciences
(SPSS-IBM) version 22.0, India. The descriptive statistics
like percentage and inferential statistics like Wilcoxon
 Manoharan, et al.: Educational intervention in medical students

signed‑rank test were applied to test the difference Table 1: Profile of the study participants (n=156)
between pre and posttest score. Variables n (%)
Age (years)
Ethical considerations 19‑20 88 (56.4)
Written informed consent was obtained from each 21‑22 65 (41.7)
study participants. The institutional ethical committee >22 3 (1.9)
approval was obtained before the initiation of the study. Gender
Male 91 (58.3)
Results Female 65 (41.7)
Residence
A total of 156 participants were included. Of 156 Hosteller 103 (66)
Day scholar 54 (34)
participants, 91 (58.3%) were females and 65 (41.7%)
Religion
were males. The mean age of the study participants
Hindu 135 (86)
was 20.28 (±1.6) years. Majority (66%) of the study
Muslim 10 (6.4)
participants were hostellers and 135 (86%) were Hindu
Christian 10 (6.4)
by religion [Table 1]. Jain 1 (0.3)

Adequate knowledge was found on domains such

as epidemiology of rabies, prophylaxis and program Table 2: Comparison of the proportion of study
participants with adequate knowledge pre‑ and
guidelines before educational intervention. The score
postintervention
obtained on these domains was 75.7%, 42.4%, and 70.8%,
Domain Knowledge Pretest, n (%) Posttest, n (%) P*
respectively. There has been considerable improvement
Epidemiology Adequate 118 (75.7) 145 (93.1) <0.01
in knowledge after intervention among the study Inadequate 38 (24.3) 11 (6.9)
participants in epidemiology (93.1%), prophylaxis (97%), PrEP and Adequate 66 (42.4) 151 (97) <0.01
and program guidelines (93.8%) domains. This was PEP Inadequate 90 (57.6) 5 (3)
found to be statistically significant (P < 0.01) [Table 2]. Program Adequate 110 (70.8) 146 (93.8) <0.01
Inadequate 46 (29.2) 10 (6.2)
Scores *Mc Nemar’s test was used. PEP=Postexposure prophylaxis,
The maximum score of domains for both pre and post PrEP=Preexposure prophylaxis

tests were 10, 17, and 2 for epidemiology of rabies,

prophylaxis, and program guidelines respectively. The Table 3: Comparison of pre‑ and posttest scores of
overall total maximum for pre and post test evaluation domains on rabies among medical students (n=156)
Domains Mean±SD Z P*
was 29.
Pretest score Posttest score

The mean pretest and posttest scores scored by Epidemiology 6.09±3.74 8.09±3.22 −6.79 <0.01
PrEP and PEP 7.95±5.1 13.26±4.56 −9.43 <0.01
participants in epidemiology, prophylaxis, and program
Program guidelines 0.85±1.3 1.35±1.18 −5.07 <0.01
guidelines domains were (6.09 vs. 8.09); (7.95 vs. 13.26),
Total score 14.90±3.70 22.70±3.23 −9.37 <0.01
and (0.85 vs. 1.35) respectively. There was a statistically *Wilcoxon signed‑ranks test. SD=Standard deviation, PEP=Postexposure
significant improvement in the scores of all the three prophylaxis, PrEP=Preexposure prophylaxis
domains after educational intervention [Table 3]. The
overall total mean pretest total score was 14.9 (±3.7), In our study, adequate knowledge on epidemiology
and posttest score was 22.7 (±3.23) out of 29. There was of rabies, correct prophylaxis, and prescribed program
a statistically significant improvement in the total scores guidelines was found in 75.7%, 42.4%, and 70.8% of study
after health education [Table 3 and Figure 1]. participants respectively. The present study results were
found to be similar with previous study findings.
Discussion
A study done by Praveen and Rajashekar reported
In the present study, it was found that there has been that 42.2%–97.7% of the participants were aware of
a statistically significant improvement in the total the various aspects of epidemiology and transmission
scores after health education. The mean pretest scores and 2.2%–61.1% were aware of the various aspects
for epidemiology, prophylaxis, and national program of PEP. [7] Shashikantha et al. reported that 74% of
guidelines domains were 6.09 (60.1%), 7.95 (46.8%), the study participants were aware of dog bite as the
and (42.5%) respectively. The knowledge pertaining to mode of transmission, 68.8% about hydrophobia as a
epidemiology domain was much better compared to sign of rabies, 62%–72% about the different categories
knowledge pertaining to PrEP and PEP and national of wounds, and 10%–52% about the various aspects
program guidelines. of PrEP and PEP.[8] Chowdhury et al. in their study
Journal of Education and Health Promotion | Volume 8 | October 2019 3
 Manoharan, et al.: Educational intervention in medical students
Figure 1: Comparison of pretest and posttest total scores of the study
participants (n = 156)
conducted on medical interns have reported that 27.5%–
95% were aware of the different categories of wounds,
10%–73.8% about the various aspects of vaccine
administration, 10%–85% about the various aspects of
immunoglobulin administration, and 60%–77% about
the various aspects of wound management.[9] A study
by Jana et al.[10] reported that awareness regarding
prophylaxis in general population was comparatively
less (43.5%), and in a study by Prakash et al.,[11] the
authors reported that 55.5% of the participants are
aware of prophylaxis of rabies after dog bite. A study
by Sarkar et al.[12] found that only 50% of students were
aware about ARV schedule.
After health education, it was observed that there has
been significant improvement in adequate knowledge in
epidemiology (93.1%), prophylaxis (97%), and program
guidelines (93.8%) domains. There was increase in
post test scores for the domains like epidemiology of
rabies, PrEP and PEP and national program guidelines.
The scores were 8.09 (80.1%), 13.26 (78%) and 1.09
(54.5%) respectively which was found to be statistically
significant. Practical oriented teaching of management
of animal bites as per health program guidelines and
periodical, interactive, continued medical education
would help in addressing knowledge gaps of students
and practicing physicians.
The limitation of the study was that the findings could
not generalized since it was single centered study.
Multicentric study including both public and private
medical schools could have been better in concluding
on the strategy followed in this educational intervention.
Conclusions
The baseline knowledge of the study participants
pertaining to epidemiology domain of rabies was
reasonably good but that pertaining to PrEP and
PEP and national program guidelines domains was
4 Journal of Education and Health Promotion | Volume 8 | October 2019
below par. There has been significant improvement in
the scores of all the three domains after educational
intervention. PrEP and PEP, and national program
domain of rabies need to be emphasized more during
health education sessions. Animal bite cases are more
common at all medical institutions (both public and
private), and lack of adequate knowledge on rabies
prophylaxis and health program guidelines would
lead to loss of lives of patients which could have been
otherwise saved.
Acknowledgment
We thank all the study participants who agreed to
participate in pre‑ and postintervention session.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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